Basic Information
| Provider Information | |||||||||
| NPI: | 1699188490 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATKINS | ||||||||
| FirstName: | BRENTON | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WATKINS | ||||||||
| OtherFirstName: | BRENT | ||||||||
| OtherMiddleName: | THOMAS | ||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7507 E. TANQUE VERDE ROAD | ||||||||
| Address2: | 101 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207222585 | ||||||||
| FaxNumber: | 5207221097 | ||||||||
| Practice Location | |||||||||
| Address1: | 7507 E. TANQUE VERDE ROAD | ||||||||
| Address2: | 101 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207222585 | ||||||||
| FaxNumber: | 5207221097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2014 | ||||||||
| LastUpdateDate: | 07/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 53883 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | R74381 | AZ | N | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.